International Medical Treatment Claim Form
1. Member Details
Policy Number
Member Name
Date of Birth
Contact Number
Address
Email
2. Patient Details (if not member)
Patient Name
Relationship to Member
Date of Birth
3. Treatment Information
Hospital/Clinic Name
Country
Admission Date
Discharge Date
Diagnosis / Reason for Treatment
Details of Treatment
4. Claim Details
Currency
Total Amount Claimed
Breakdown of Claimed Amount
Are you covered by any other insurance?
Yes
No
If Yes, provide details
5. Bank Details for Reimbursement
Bank Name
Account Holder Name
Account Number
SWIFT / BIC
Bank Address
6. Declaration
I hereby certify that the information provided is true and complete.
Signature
Date